An open letter to the health secretary: how to really save money on the NHS
BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c5618 (Published 14 October 2010) Cite this as: BMJ 2010;341:c5618
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I could not agree more with the author's views on end-of-life care.
My experience as a NHS GP over the last 20 years is that the NHS is
spending more and more on 'heroic' acute hospital interventions to prolong
the life of elderly patients.
I fear that much of this driven by the fear of medico-legal jeopardy;
hospital doctors do not wish to be litigated or complained against for
refusing to treat patients (on the grounds that highly invasive treatments
on elderly patients are severely deleterious to the patient's quality of
life) for fear of being regarded as being diffident about the patient
dying.
More importantly, the GMC's latest Good Medical Practice publication,
'Treatment and Care towards the end of life: good practice in decision
making' drives a coach and horses through the ethic that prolonging a
patient's life at all costs is neither moral nor affordable, with its
emphasis on Presumption in favour of prolonging life (paragraph 10).
Which doctors will be courageous enough to risk inviting actions by
lawyers representing patient relatives or facing a GMC Fitness to Practise
Panel in this brave new world?
Competing interests: No competing interests
Sir
Sir Peter Lachmann (1) (16 October) refers to the statistic from RAND
that at least a third of "a person's lifetime healthcare expenditure is
spent in the last six months of their life". However, he is too negative.
In 2004, Baicker and Chandra (2) found that "[US] States with more
general practitioners use more effective care and have lower spending,
while those with more specialists have higher costs and lower quality",
and this finding particularly applied to end of life care. They advise
that better balancing of the main branches of medicine can contribute to
both quality of care and value for money.
Medical generalists who know their patients and families are best
placed to negotiate the cessation of costly investigations and active
treatment and the use of palliative care for those who are close to death.
Yours faithfully
Sir Denis Pereira Gray OBE HonDSc FRCP FRCGP FMedSci
Exeter, EX2 4TJ
References
1. Lachmann P. An open letter to the health secretary: how to really
save money on the NHS. BMJ 2010: 341, c5618.
2.Baicker K, Chandra A. Medicare spending, the physician workforce,
and beneficiaries' quality of care. Health Aff (Millwood)2004 Suppl web
exclusives) W4-184.
Competing interests: No competing interests
Dear Editor,
Peter Lachmann (Personal view BMJ 2010; 341:c5618) is correct that
his suggestions to save money within the NHS are not universally popular.
Unfortunately the editing of his views for the printed journal, may
exacerbate this.
There will be many who object to the suggestion that 'end of life
care' is an expensive and unnecessary provision. Whilst it is evident, in
the full text version, that Peter Lachmann does not mean 'end of life
care' in the sense of providing supportive and palliative care including
symptom control when other treatment aims are no longer appropriate, the
opposite impression is given in print. Palliative care, at all stages of
illness, to provide symptom control rarely approaches even a fraction of
the cost of the other two ways suggested for cost reduction.
What is expensive is not end of life care but decisions to continue
non-palliative medical interventions which are futile. This is extremely
subjective, and if facing the possibility of 'a few more months to live'
then this is likely to seem worthwhile to at least some. The duty of a
doctor to an individual patient should include discussion about that
patient's preferences for care at the end of life. This discussion should
not be replaced by questionable interventions without realistic hope of
success, although it has to be recognised that this can sometimes only be
judged in hindsight.
This is not related, as suggested, to a right to die, should such a
right exist. Nor, given the complex arguments related to interpretations
of evidence surrounding doctor assisted suicide, is it appropriate in a
few sentences to assert that this is not problematic, or to reduce all
theological considerations, from any religion, to one abstracted idea.
A more fruitful debate might be had if we were to explicitly address
what might constitute fair rationing of treatments within the NHS, rather
than simply suggesting death as a means to save money.
Yours sincerely,
Sarah Yardley
Competing interests: No competing interests
As one would expect, Sir Peter Lachmann's views on how to save money
for the NHS (BMJ 2010;341:c5618) are thought provoking. His suggestions
regarding making 24 hour 7 day a week use of medical facilities, and
avoidance of expensive, undignified and futile measures near the end of
life, accord with my personal views. His case for making drugs available
immediately after phase II trials is more controversial.
Phase III trials
are indeed imperfect in detecting adverse effects and are not always
needed to prove efficacy; but a string of unexpected but crucial results
from phase III studies over the past 60 years suggest that in many
instances it would be unwise to dispense with them before drug
registration. Examples range from discoveries regarding streptomycin
resistance in tuberculosis treated with this drug as a single agent (the
classic MRC trial of Bradford Hill), through increased mortality caused by
class Ic and III "anti-dysrhythmic" drugs in patients with ventricular
ectopics (the CAST and SWORD studies) and in patients with heart failure
treated with positive inotropes (amrinone, milrinone), to more recent
concerns over increased cardiovascular risk leading to voluntary
withdrawal of rofecoxib (Vioxx) and regulatory restrictions on
rosiglitazone (Avandia). Early meetings between senior industry- and
regulatory-based clinical pharmacologists to discuss regulatory
requirements for each new drug on an individual basis can help to
streamline the development process without loss of scientific rigor, and
is the better way forward.
Competing interests: No competing interests
I agree entirely with Dr Lachman's comments. Over and above his
suggestions, I'd like to add that in the last few years on the back of
revalidation, MMC and cancer services there has been a mushrooming of new
courses at the cost of the tax payer. Many of these such as a three day
communications courses for consultants, leadership courses for all are
draining our resources with no proven benefit. A large DGH such as ours
with over 150 consultants will have to put up with the burden of loss of
productivity primarily due to lost working time. Some of these courses can
be as long as three days and translates to 450 working days lost for
one DGH. Do we really think that attending course such as these and
leadership courses really add value? Should some one in the Department of
Health not be looking into this wasteful expenditure?
Competing interests: No competing interests
Assisted dying saves the NHS money
I must have been on holiday at the time this personal view was
published in October so I have read it only recently but was so horrified
by the views expressed by this article that even as late as Christmas eve
I fell I have to reply.
I have not had the pleasure of meeting Sir Peter Lachman but I wonder if
he might look again at what he has written with the eyes of someone with a
chronic disease or disablity, or one who cares for such a person, and who
wishes to enjoy all the fullness of life that they have left to them.
Sir Peter's article is likely to give them a feeling of guilt as he has
made them believe that they are a burden to the the NHS and their fellow
taxpayers.
The free world shed much blood from 1939-1945 to defeat faschism yet it's
philosophy seems to live on in the minds of those who advocate saving
money by introducing "voluntary" euthanasia.
Competing interests: No competing interests